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American Association of Plastic Surgeons
89th Annual Meeting Abstracts

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Functional, Psychological and Quality of Life Outcomes after Mandibular Reconstruction for Osteoradionecrosis with Osseocutaneous Free Flaps in Oral Cancer Patients
Stefan O. Hofer, M.D., Ph.D.1, Caroline Payne, M.D.1, Ralph Gilbert, M.D.1, Gerald Devins1, David Goldstein, M.D.1, Jolie Ringash, M.D.2.
1Toronto General Hospital, Toronto, ON, Canada, 2Princess Margaret Hospital, Toronto, ON, Canada.

Background: Osteoradionecrosis (ORN) is a rare and important complication of radiotherapy. Surgical excision followed by microvascular mandibular reconstruction is the gold standard treatment for severe ORN and it is important to understand the long-term outcomes of this procedure.
Purpose: The primary objective was to compare the functional, psychological and disease-specific Quality of Life (QOL) outcomes in oral cancer patients following conservative vs. surgical treatment with resection and microvascular reconstruction of ORN.

Methods: Oral cancer patients treated with radiotherapy at the Princess Margaret Hospital - Wharton Head and Neck Cancer Centre between January 1999 and 2009 provided data.
Two ORN treatment groups were identified: ORN surgical group 1 - treated with resection and microvascular mandibular reconstruction. ORN conservative group 3 - developed ORN following radiation, and received conservative management.
The two ORN treatment groups were matched on age, sex and time since radiation therapy with two non-ORN oral cancer patient groups: Non-ORN surgical group 2 - treated with surgical excision, mandibular reconstruction/radiation. Non-ORN group 4 - treated with radiation therapy alone. One time surveys were administered by mail.
Measures: Emotional wellbeing was evaluated by the Center for Epidemiologic Studies Depression Scale (emotional distress), Affect Balance Scale (psychological well-being), and the Atkinson Life Happiness Rating Scale. Treatment-related concerns were measured using Andrykowski's "Back to Normal" question and a Fear-of-Cancer-Recurrence question. Quality of life was evaluated using the European Organization for Research and Treatment of Cancer (EORTC) HN37.

Results: A multivariate analysis of covariance was performed comparing the 4 matched treatment groups and controlling for empirically identified covariates including pain, swallowing, sensation and speech.
Controlling for general health and recent stressful life events, ORN surgical group 1 and non-ORN surgical group 2 reported significantly higher subjective wellbeing as compared to the non-surgically treated ORN conservative group 3 (p=0.02) (Fig 1: Graph 1); this difference was due largely to depressive symptoms.
Controlling for current symptom burden, ORN groups 1 & 3 reported significantly more fear of cancer recurrence and concern about returning to normal compared to the non-ORN group 4 (p=0.02), (Fig 1: Graph 2).
Controlling for treatment related side effects, disease-specific health-related quality of life (specifically, social eating, social contact and sexuality) did not differ significantly across the groups (Fig 1: Graph 3).
Conclusions: Although mandibular reconstruction for oral cancer patients with ORN is an effective treatment, its impact on QOL is not uniform across procedures. Surgically managed groups reported greater subjective wellbeing, despite more invasive treatment, yet both ORN groups reported greater fear of recurrence and concern about returning to normal. Evaluations of QOL in head and neck cancer should attend to a broad range of outcomes, rather than limiting the focus to disease-specific health-related QOL to avoid overlooking important, but subtle effects.

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